European Review for Medical and Pharmacological Sciences

2012; 16: 2021-2028

The use of high resolution magnetic resonance

on 3.0-T system in the diagnosis and surgical
planning of intraosseous lesions of the jaws:
preliminary results of a retrospective study
M. CASSETTA, S. DI CARLO, N. PRANNO, A. STAGNITTI*, V. POMPA, G. POMPA
Department of Oral and Maxillofacial Sciences, School of Dentistry, Sapienza University of Rome,
Rome, Italy
*Department of Radiological Sciences, Sapienza University of Rome, Rome, Italy

Abstract. BACKGROUND: The pre-operative evaluation in oral and maxillofacial surgery

is currently performed by computerized tomography (CT). However in some case the information of the traditional imaging methods are not
enough in the diagnosis and surgical planning.
The efficacy of these imaging methods in the
evaluation of soft tissues is lower than magnetic
resonance imaging (MRI).
AIM: The aim of the study was to show the
use of MRI in the evaluation of relation between
intraosseous lesions of the jaws and anatomical
structures, when it was difficult using the traditional radiographic methods, and to evaluate the
usefulness of MRI to depict the morphostructural characterization of the lesions and infiltration
of the soft tissues.
MATERIALS AND METHODS: 10 patients with
a lesion of jaw were selected. All the patients underwent panoramic radiography (OPT), CT and
MRI. The images were examined by dental and
maxillofacial radiology who compared the different imaging methods to analyze the morphological and structural characteristics of the lesion
and assessed the relationship between the lesion and the anatomical structures.
RESULTS: Magnetic resonance imaging provided more detailed spatial and structural information than other imaging methods.
CONCLUSIONS: MRI allowed us to characterize the intraosseous lesions of the jaws and to
plan the surgery, resulting in a lower risk of
anatomic structures surgical injury.
Key Words:
Odontogenic tumours, Odontogenic cysts,
Mandibular nerve, Tomography X-Ray computed,
Magnetic resonance imaging.

Introduction
Benign odontogenic tumours and cysts are
asymptomatic intraosseous lesion that can affect

the bones of the maxillomandibular complex.

Ameloblastomas and keratocystic odontogenic tumours are major aggressive odontogenic tumours1.
These tumours are characterized by a low speed
expansion and they are frequently associated to a
local invasion of the contiguous epithelial areas2.
Both tumours show more frequently a localization
at the angle of the mandible, extending anteriorly
and superiorly, and common radiologic features
such as unilocular or multilocular radiolucencies
with a characteristic soap bubble shape2. A radiological differentiation between ameloblastomas
and keratocystic odontogenic tumours lesions is
not difficult if the lesions show their characteristic
aspect. However, some time, these tumours appear
as unilocular and the differential diagnosis with
the other damages is difficult. The pre-operative
evaluation in oral and maxillofacial surgery is currently performed by several imaging methods.
One of the principal difficulties in the planning of
surgery is to define the anatomic relation between
the lesion and peripheral nerves. In particular, the
evaluation of the spatial relationship between the
inferior alveolar nerve (IAN) and a mandibular lesion is important to avoid injuries of this anatomic
structure3-5.
Both panoramic radiography (OPT) and computerized tomography (CT) can be used to detect
the bone structures. However, the efficacy of
these imaging methods in the IAN detection is
lower than magnetic resonance imaging (MRI).
In fact, while CT and OPT depict the bone of the
mandibular canal, MRI allows a significant appreciation of its contents6-9.
Matsuzaki et al10 also showed the utility of the
MRI in the pre-surgical approach, especially in
the evaluation of soft tissue invasion in
ameloblastic carcinoma in the right anterior maxillary sinus.

Corresponding Author: Michele Cassetta, DDS, Ph.D.; e-mail: michele.cassetta@uniroma1.it

2021

M. Cassetta, S. Di Carlo, N. Pranno, A. Stagnitti, V. Pompa, G. Pompa

The aim of the present study was to show the

use of MRI in the evaluation of relation between
intraosseous lesions of the jaws and the anatomical structures, when it was difficult using the traditional radiographic methods, and to evaluate
the usefulness of MRI to depict the morphostructural characterization of these lesions and infiltration of the soft tissues.

Materials and Methods

Patient Population
A total of 10 patients, six men and four
women (age range: 21-63 years; means: 38.8
years), who had a lesion of jaws, were selected at
the Department of Oral and Maxillofacial Sciences of Sapienza University of Rome (Table I).
All patients, between January 2004 and April
2010, underwent OPT, CT and MRI to provide a
careful morphostructural characterization and
evaluation of spatial relationship between the lesion and the anatomic structures. All images were
analyzed by dental and maxillofacial radiologist.
CT Imaging
CT examinations were performed in high resolution helical CT machines (CT scan Siemens
Somatom, Erlangen, Germany) using a bone algorithm, 0.6 mm slice collimation, 24 cm field of
View (FOV), 512 512 matrix, 120 kV and 150
mAs. The data were transferred to the workstation for post-processing. Three sets of reconstruction images were displayed: Axial, Sagittal
and Coronal.
MR Imaging
MRI scan with a 3.0 T machine (Discovery
750 General Electric, Milwaukee, WI, USA) was
performed with head-neck coil. Since the maxillofacial area is composed by a high percentage
of fat and fluid, the study of this region could not
be performed by means of routine conventional
techniques of MRI. Consequently, our protocol
was carried out using the following sequences:
1. T2-weighted axial images acquired with a fast
spin echo interactive decomposition of water
and fat with echo asymmetry and least-squares
estimation (FSE IDEAL) using a repetition
time (TR) of 3038 ms, echo time (TE) of 124
ms, field of view (FOV) of 24 24 cm, slicethickness (SL) of 4 mm, and number of excitations (NEX) of 3.
2022

2. T1-weighted axial images fat-saturated fast

spin echo pre-contrast administration (Ax T1
Fs FSE pre-CE) and post-contrast administration (Ax T1 Fs FSE post-CE) using a repetition time (TR) of 418 ms, echo time (TE) of 8
ms, field of view (FOV) of 25 25 cm, slicethickness (SL) of 4 mm, and number of excitations (NEX) of 2 to evaluate the potential enhancement of the mass.
The contrast index (CI) pre- and post-contrast
administration was calculated using one region
of interest (ROI) in the centre of the tumour mass
(a ROI in the muscular tissue was used as a control-image). Contrast-enhanced MRI (CE-MRI)
with gadoteric acid (Dotarem, 12 ml) was performed to evaluate possible soft tissue invasion
and to investigate the benign nature of the lesion.
3. Diffusion weighted imaging (DWI b = 800)
using a repetition time (TR) of 4375 ms, echo
time (TE) of 72 ms, field of view (FOV) of 23
23 cm, slice-thickness (SL) of 5 mm, bandwidth (b) of 800 s/mm2 and number of excitations (NEX) of 1.
4. T1-weighted fast imaging employing steadystate acquisition (FIESTA) using a repetition
time (TR) of 4.6 ms, echo time (TE) of 2.2 ms,
field of view (FOV) of 24 24 cm, slice-thickness (SL) of 0.6 mm and number of excitations (NEX) of 1 and T1-weighted fast spoiled
gradient-recalled echo (fast SPGR) using a
repetition time (TR) of 7.8 ms, echo time (TE)
of 3.2 ms, field of view (FOV) of 23.5 23.5
cm, slice-thickness (SL) of 0.6 mm and number of excitations (NEX) of 2.
For the criteria of the signal intensity the cerebrospinal fluid was defined as a bright hight signal on T2WI and muscolature as a intermediate
signal on T1WI.

Results
This study included 10 patients. The histological diagnosis was dentigerous cysts in 8 patients,
unicystic ameloblastoma in 1 patient and solid/
multicystic ameloblastoma in 1 patient (Table I).
In the Water: (T2 FSE-IDEAL) the odontogenic cyst and unicystic ameloblastoma appeared
as a homogeneously high signal intensity region,
and it was characterized by homogeneously intermedial intensity in the Fat: (T2 FSE-IDEAL).
Otherwise ameloblastoma solid/multicystic
appeared as a high signal intensity region in the

27

63

35

45

43

31

52

21

23

48

10

Age Sex

Left mandibular ramus

Right mandibular ramus

Left maxillary region

Right mandibular molar

Right mandibular ramus

Left mandibular ramus

Left mandibular ramus

Left mandibular ramus

Maxillary anterior region

Left maxillary region

Region

Table I. Clinical and MR imaging features.

Homogeneously
intermediate
Homogeneously
intermediate
Homogeneously
intermediate
Homogeneously
intermediate
Intermedial
(cystic portion)
Intermediate
(solid portion)
Homogeneously
intermediate
Homogeneously
intermediate
Homogeneously
intermediate
Homogeneously
intermediate
Homogeneously
intermediate

T1-weighted
image

Homogeneously high

Homogeneously high

Homogeneously high

Homogeneously high

Homogeneously intermediate

Homogeneously intermediate

Homogeneously intermediate

Homogeneously intermediate

High-intermedial
(solid portion)
Homogeneously intermediate

High (solid portion)

Homogeneously high

High (cystic portion)

Homogeneously intermediate

Homogeneously intermediate

Homogeneously intermediate

Homogeneously intermediate

Fat T2weighted image

Bright high (cystic portion)

Homogeneously
bright high
Homogeneously high

Homogeneously high

Homogeneously high

Water T2weighted image

Thin rim enhancement

Thin rim enhancement

Thin rim enhancement

No enhancement
(cystic portion)
Good enhancement
(solid portion)

Thin rim enhancement

Thick rim enhancement

Thin rim enhancement

Thin rim enhancement

Contrast-enhanced
T1-weighted image

Odontogenic cysts

Odontogenic cysts

Odontogenic cysts

Odontogenic cysts

Odontogenic cysts

Solid/multicystic type
of ameloblastoma

Unicystic type of
ameloblastoma
Odontogenic cysts

Odontogenic cysts

Odontogenic cysts

Histopathological
diagnosis

HRMR on 3.0-T system in the diagnosis and surgical planning of intraosseous lesions of the jaws

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M. Cassetta, S. Di Carlo, N. Pranno, A. Stagnitti, V. Pompa, G. Pompa

Water: (T2 FSE-IDEAL) and it was characterized

by hight-intermedial intensity in the Fat: (T2
FSE-IDEAL). Both the sequences unveiled an
heterogeneous pattern within the tumour mass
(Figure 1).
Ax T1 Fs FSE pre-CE in the odontogenic cyst
and unilocular cystic-type ameloblastomas
showed homogeneous intermediate signal intensity. In the solid/multicistic ameloblastomas Ax
T1 Fs FSE pre-CE showed intermedial signal intensity in cystic and solid portion.
Ax T1 Fs FSE post-CE in the odontogenic
cyst and unilocular cystic-type ameloblastomas
showed a thick or thin rim enhancement. In the
solid/multicistic ameloblastomas Ax T1 Fs FSE
post-CE showed an area of solid component
characterizad by a good enhancement.
No significant differences were observed in
the CI between the two ROIs in the lesions (Figure 2).
The DWI sequence showed in three patients
hypointense lymph nodes, increased in size, ipsilateral to the lesion (Figure 3).
3D FIESTA and fast-SPGR are both three dimensional sequences that visualize directly the
reciprocal relationship between the anatomic and
pathological structures, in particular is possible
to assess the IAN course. In the 100% of the cases we were capable to value the spatial relation
between the lesions and the anatomical structures
using the 3D FIESTA and SPGR scan (Figure 4).
CT scans in all patients detected the bone
structures providing an high spatial resolution.

However, in two cases, when the lesion induced the resorption of the roof of the mandibular canal, the IAN could not be identified by CT
(Figure 4).

Discussion
MRI images of intraosseous lesions of the
jaws provided additional information compared
to CT in the several sequences that have been
used in the present study.
The IDEAL sequence allowed to acquire 3 images with different phase shifts between water
and fat saturation thus leading to the possibility
to distinguish water and fat images and the field
map. In order to obtain this separation, iterative
fat-water decomposition algorithm and a 3-echo
data acquisition, with the center echo shifted relative to the SE point, were combined. This sequence allowed to depict the component (solid or
liquid) of the lesion. On this T2-weighted images
(T2WI) the signal intensity of a lesion was designated as homogeneously high or intermedial in
the odontogenic cyst and unilocular cystic-type
ameloblastomas. Otherwise, ameloblastoma solid/multicystic appeared as a high or intermedial
signal intensity region. On T1-weighted images
(T1WI) odontogenic cyst and unilocular cystictype ameloblastomas were designated as homogeneous intermediate signal intensity area. The
solid/multicistic ameloblastomas showed intermedial signal intensity in cystic and solid por-

Figure 1. T2-weighted axial images acquired with a fast spin echo interactive decomposition of water and fat with echo
asymmetry and least-squares estimation (FSE IDEAL). Water (A) and Fat (B) (T2 FSE-IDEAL) show an heterogeneous pattern within the solid/multicistic ameloblastomas tumour mass.

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HRMR on 3.0-T system in the diagnosis and surgical planning of intraosseous lesions of the jaws

Figure 2. T1-weighted axial images fat-saturated fast spin echo (Ax T1 Fs FSE). A, Pre-contrast administration (Ax T1 Fs
FSE pre-CE). B, Post-contrast administration (Ax T1 Fs FSE post-CE). The post-CE acquisition shows that the contrast is confined to the margin of the lesion,characteristic image of the benign tumour with the presence of a capsule. Two ROIs corresponding to the lesion (1) and to the muscular tissue (2) were determined in the pre (C) and post-contrast administration (D)
sequences. A significant different gradient between the two sequences was detected only in the muscular tissue. Consequently
no mass enhancement was observed.

tion. The characteristic heterogeneous pattern

within this tumour mass was due to his multicystic and solid structure. Otherwise, homogeneously hight/intermedial signal intensity on
T2WI and homogeneously intermediate signal
intensity on T1WI reflected the fluid content of
the inner part of odontogenic cyst and unilocular
cystic-type ameloblastomas. T1WI post-contrast
administration revealed an encapsulated lesion
and highlighted well defined margins. This finding allowed us to assign the diagnosis of a benign
lesion. In all lesions CE-MRI showed a bright
high rim signal intensity. The only patient with

the unicystic ameloblastoma was characterize by

more thick rim enhancement useful for the differentiation of unilocular cystic-type ameloblastoma
from other cystic lesions. CE-MRI demonstrated
that the solid/multicystic ameloblastomas were
composed of varying proportion of solid (good
enhancement) and cystic (no enhancement) lesions useful in the differential diagnosis with the
other intraosseous tumours. In all lesions two
ROIs corresponding to the lesion and to the muscular tissue were determined in the pre and postcontrast administration sequences. No significant
gradient differences between the two sequences
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M. Cassetta, S. Di Carlo, N. Pranno, A. Stagnitti, V. Pompa, G. Pompa

Figure 3. Diffusion weighted imaging acquisition (DWI b = 800): A, Axial diffusion-weighted MR image at b = 800
s/mm2 shows an high signal intensity of the lesion. B-C, High resolution 3D Volume Rendering 3DVR-MRI shows enlarged
nodes, ipsilateral to the lesion, in the upper part of the neck which exhibit low signal intensity. The white arrows indicate an
enlarged node.

Figure 4. Coronal CT image of the patient with solid/multicystic ameloblastoma in the left mandible ramus (A) the relationship between the lesion and the
mandibular canal is not detectable; in the coronal T1weighted fast imaging employing steady-state acquisition (FIESTA) (B) and in the
coronal T1-weighted fast
spoiled gradient-recalled
echo (fast SPGR) (C) the relationship between the lesion and IAN (white arrows)
is clearly detectable. Sagittal
CT image of the patient with
unilocular odontogenic cyst
in the right mandibular molar area (D) the relationship
between the lesion and the
mandibular canal is not detectable; In the sagittal T1weighted axial images fatsaturated fast spin echo postcontrast administration (Ax
T1 Fs FSE post-CE) (E) the
relationship between the lesion and IAN is clearly detectable.

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HRMR on 3.0-T system in the diagnosis and surgical planning of intraosseous lesions of the jaws

were observed. Consequently no mass enhancement were observed and in all cases the infiltrations of soft tissue were negative10-12.
DWI was applied for the evaluation of intracranial diseases such as cerebrovascular accidents, trauma and epilepsy diseases such. Currently, DWI (diffusion weighted imaging) is being used for tumour detection, tumour characterisation and to differentiate neoplastic from nonneoplastic diseases, and is being employed in
various organ systems. This sequence evaluates
intercellular water motion: every change in the
water protons movements induces a variation of
signal intensity in this sequence13. DWI is currently used to improve the diagnostic accuracy in
the differential diagnosis between benign and
malignant nodes. Metastatic nodes are characterized by reduction of diffusivity, which is associated with a hypercellularity, to an increased nuclear-to-cytoplasmatic ratio and to perfusion.
This decrement in diffusion is represented as an
area of hyperintensity on diffusion images; adversely, inflammatory nodes appeared hypointense 14. In this study the DWI sequence
showed in three cases a benign latero-cervical
lymphadenopathy, ipsilateral to the lesion. No
malignant lymph nodes were observed.
3D FIESTA and fast-SPGRT used in the present study are both high reliable to provide a
precise estimation of spatial relation between
the lesions and the anatomic structures supplementing clear anatomical visualization. In particular, the 3-D FIESTA is a T2 weighted sequence widely used for the study of the intracranial path of the cranial nerves, as it performs a cisternography inside the skull and it
is used in the clinical practice to rule out the
presence of the acoustic neurinoma in the clinical suspicion of hearing loss of neurosensory
type15,16. The 3D FIESTA allows also to follow
the fifth cranial nerve, especially in his third
and main branch (the mandibular nerve) It is also possible to follow the inferior alveolar nerve
and the lingual nerve, frequently interested by
intraosseous expansive lesions, being these two
nerves the main branches of the posterior trunk
of the mandibular nerve.
The fast SPGR sequence is a T1 sequence fat
sat, giving an high contrast between the bone of the
jaw and the alveolar nerve that appear as hyper-intense inside the bone itself. Despite the low discrimination between the soft tissues the fast SPGR
(spoiled gradient-recalled) gives a very reliable and
good quality of image of the inferior alveolar

nerve, allowing to assess its path directly17. In the

100% of the cases we were capable to value the
spatial relation between the lesions and the
anatomical structures with the 3D FIESTA and SPGR scan.
CT plays an important role in the study of intraosseous lesions and in the evaluation of adjacent bone destruction18. The ability of this x-ray
method to eliminate image superimposition, to
present real dimensional values, to reconstruct
high resolution images in different planes including 3 dimensions, has established CT as the gold
standard in diagnosis and treatment planning of
this lesions19,20. In this study it revealed, in the
cases of odontogenic cyst and unilocular cystictype ameloblastomas, a unilocular radiolucency,
variable in size, presenting well defined margins.
In the case of ameloblastoma solid/multicystic
CT showed multiple-locus radiolucency presenting characteristic soap bubble shape, interesting the whole left mandibular ramus. CT scans in
all patients detected the bone structures providing an high spatial resolution. However, in two
cases, when the lesion induced the resorption of
the roof of the mandibular canal CT imaging has
provided unclear depiction of the mandibular
canal. In contrast, the present MRI protocol provided high resolution images of these anatomic
structures and it was decisive for the surgical
planning, reducing the risk of IAN damage.

Conclusions
MRI has been infrequently used for oral and
maxillofacial imaging because the acquisition of
the sequences can be invalidated by motion of
the body, respiration, air in the oral cavity and
nasal cells, implants and metal materials 3,21.
However, the utilization of MRI, allowed us a
careful evaluation of spatial relationship between
anatomic structures and intraosseous jaws lesions
when CT imaging has provided unclear depiction
of the mandibular canal. The actual study showed
that MRI could be effectively useful to the typing
of different expansive lesion, and to evaluate the
possible infiltration of the soft tissue. These informations are decisive in the differential diagnosis between the benign lesions and major aggressive odontogenic tumours and in the surgical
planning. Therefore, the capability to acquire
more news without exposing the patient to x-rays
makes the MRI an additional imaging method in
oral and maxillofacial surgery22.
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M. Cassetta, S. Di Carlo, N. Pranno, A. Stagnitti, V. Pompa, G. Pompa

However, the results of this study should be interpreted taking into account the limited number
of cases and further evaluations will be done
when will be available a wider number of cases.

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